vv ISSN: 2641-2977 DOI: https://dx.doi.org/10.17352/ahr CLINICAL GROUP Naureen Sameera*, Ishaq Aliya, Itu Lizica, Al Awa Arfan, Ghazi Esaaf, Zaid Case Report Abdul Aziz, Siddhart Sankar Das, Feras Al Khitab and Syed Javed A rare case of hepatic sub capsular Department of General Surgery, Dubai Hospital, Dubai, biloma after cholecystectomy treated by United Arab Emirates Received: 23 September, 2019 percutaneous drainage and endoscopic Accepted: 06 December, 2019 Published: 07 December, 2019 biliary stenting: A case report *Corresponding author: Naureen Sameera, Depart- ment of General Surgery, Dubai Hospital, Dubai, United Arab Emirates, E-mail: Keywords: Bilomas; Sub capsular; Bile leak Abstract https://www.peertechz.com Bilomas are localized collections of bile which usually happen post-operatively from an injured cystic or bile duct and most of the biloma collections are in the sub hepatic space. We describe a rare case of hepatic subcapsular biloma after open cholecystectomy which was successfully treated by percutaneous drainage. Background adhesions noted at the level of callot’s triangle making anatomy identifi cation extremely diffi cult, subtotal cholecystectomy Bile leak after laparoscopic open or cholecystectomy usually was performed, due to fl ogistic pseudo-tumor as e result of happens due to unidentifi ed minor biliary injury, however, previous attacks of cholecystitis. sometimes it can reveal a major duct injury as well. Mostly the cause is iatrogenic injury and trauma, and mostly located in the Post operatively, the patient remained in hospital for sub-hepatic space. More than 50% cases originate from the cystic pain control and chest physiotherapy. On the seventh post- duct [1]. Hepatic sub capsular bilomas are mostly happening as a operative day, she became pyrexial and started to complain of complication after cholecystectomy. We describe an interesting increased pain in the right upper quadrant of her abdomen. On case of a 46-year-old woman, who was electively admitted for examination, she had a temperature of 38 degrees, a pulse rate laparoscopic cholecystectomy for symptomatic gallstones and of 100(bpm) and a blood pressure 140/80mm Hg. Abdominal due to peroperative fi ndings of a mass formation, underwent examination was unremarkable apart from mild tenderness open cholecystectomy, a week later developed fever and right around her cholecystectomy scar. Laboratory data revealed upper quadrant abdominal pain and diagnosed by a Computed hemoglobin of 8.7g/dl, white blood cells of 15,600/mm with Tomography (CT) and ultrasound as subcapsular biloma and, neutrophilia 83%. Liver enzymes showed a total bilirubin of which was successfully treated by percutaneous drainage and 0.7mg/dl; SGPT was 35U/L and alkaline phosphatase was Endoscopic Retrograde Cholangiopancreatography (ERCP). 320U/L. Ultrasonography (US) of the abdomen revealed a large There are some cases reported in the literature about this fl uid-fi lled collection in the right lobe of the liver extending complication after laparoscopic cholecystectomy [2], but in our laterally without any free intra-abdominal fl uid. Thoraco- institute this complication was dealt in for the fi rst time, and abdominal Computed Tomography (CT) confi rmed the was successfully managed non-surgically. results of the US and concluded a large hepatic sub capsular biloma measuring (20cm×4cm×4.5cm). Based on the imaging Case Presentation fi ndings, we made a decision to perform a percutaneous US guided drainage of the collection which drained 800ml of frank A 46-year-old Pakistani lady was electively admitted for bile (Figures 1-5). cholecystectomy due to symptomatic gallstones and repeated episodes of cholecystitis in the near past. Her past history was After draining the bile, a drainage catheter was unremarkable in terms of any previous surgery or chronic positioned and left in place. Meanwhile the patient was also illness. Peroperative laparoscopic fi ndings revealed peri- referred to Gastroenterology as the alkaline phosphatase cholecystic adhesions and mass formation, so the decision level was still high and decision of endoscopic retrograde was to convert to open cholecystectomy. Due to the extensive cholangiopancreatography (ERCP) was done on 14th 027 Citation: Sameera N, Aliya I, Lizica I, Arfan AA, Esaaf G, et al. (2019) A rare case of hepatic sub capsular biloma after cholecystectomy treated by percutaneous drainage and endoscopic biliary stenting: A case report. Arch Hepat Res 5(1): 027-029. DOI: https://dx.doi.org/10.17352/ahr.000024 https://www.peertechz.com/journals/archives-of-hepatitis-research postoperative day with sphincterotomy and 7 Fr plastic stent placement with good bile drainage internally. The external catheter drained more than 500 ml of bile over 5 days and it was removed 5 days later when the output was gradually ceased and, a follow up US showed a near-complete resolution. No complication occurred. The patient had repeat ERCP after 10 weeks and uneventful removal of the biliary stent was done. We noted that the liver enzymes were normal a week later following drainage. The patient was free of any symptoms at the 2months follow up. A further USS performed after six months later was normal and, did not show any abnormalities. Discussion Figure 5: Ultra sonography showed nearly resolving biloma, with persistence of a little collection measuring 3.7×0.5×3.7cm, volume 3-5ml. The word biloma was introduced in 1979 by Gould and Pater to defi ne a localized collection of bile outside the biliary tree. Bilomas mainly result from iatrogenic, traumatic, or spontaneous rupture of the biliary tree [3]. Although leakage of bile into the peritoneal cavity is a known complication after cholecystectomy [4], the hepatic subcapsular biloma is a rare complication after cholecystectomy. Some authors attribute this complication due to damage to small biliary radicles with the high-pressure irrigation used during choledochoscopy as well [5]. Also during endoscopic retrograde cholangiopancreatography ERCP, the pressure transmitted to biliary radicles by injection of contrast material is the reported as a cause of a hepatic subcapsular biloma in cases linked to ERCP [6]. The possible etiology for the hepatic subcapsular biloma in our patient is direct disruption of a small biliary radical near the gallbladder bed during surgical dissection, because the procedure was technically diffi cult and the anatomy was not clear. Figure 1: Abdominal CT (axial) demonstrated subcapsular collection in the right Ultrasound has high sensitivity and specifi city for diagnosis lobe of the liver. of bilomas, but nowadays computed tomography is warranted to rule out any other associated pathology [7]. Magnetic resonance cholangiopancreatography or MRCP might be needed in some cases to delineate the biliary system and to rule out major duct injury [5]. Hepatic subcapsular biloma can be drained percutaneously under radiological guidance, which has been reported as a standard treatment with excellent results [5-8]. Conclusion Sub capsular bilomas are rare complications of Figure 2: Abdominal CT (coronal) demonstrated subcapsular collection in the right cholecystectomy. Early diagnosis and radiologically guided lobe of the liver. percutaneous drainage are the key to successful management and outcome of this exceptional complication. References 1. De Palma GD, Galloro G, Iuliano G, Puzziello A, Persico F, et al. (2002) Leaks from laparoscopic cholecystectomy. Hepatogastroenterology 49: 924. 2. Hassani KI, Benjelloun el B, Ousadden A, Mazaz K, Taleb KA (2009) A rare case of hepatic sub capsular biloma after open cholecystectomy: a case report. Cases J 2: 7836. Link: http://bit.ly/2DNhKZM 3. Christoforidis E, Vasiliadis K, Goulimaris I, Tsalis K, Kanellos I, et al. (2007) A Single Center Experience in Minimally Invasive Treatment of Postcholecystectomy Bile Leak, Complicated with Biloma Formation. J Surg Res 141: 171-175. Link: http://bit.ly/2LthbZs Figures 3,4: ERCP and plastic stent placement. 028 Citation: Sameera N, Aliya I, Lizica I, Arfan AA, Esaaf G, et al. 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McLindon JP, England RE, Martin DF (1998) Causes, clinical features and Hepatic subcapsular biloma. An unusual complication of endoscopic non-operative management of bile leaks. Eur Radiol 8: 1602-1607. Link: http://bit.ly/33VJlTl Copyright: © 2019 Sameera N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 029 Citation: Sameera N, Aliya I, Lizica I, Arfan AA, Esaaf G, et al. (2019) A rare case of hepatic sub capsular biloma after cholecystectomy treated by percutaneous drainage and endoscopic biliary stenting: A case report. Arch Hepat Res 5(1): 027-029. DOI: https://dx.doi.org/10.17352/ahr.000024.